Hopkins Residency Loses Accreditation

Hi Folks,
The Internal Medicine Residency at Johns Hopkins lost accreditation by the ACGME for violating the 80-hour work week. They will not be accredited next year but those folks graduating this year will be all right. The RRC is very serious about not working more than 80-hours averaged over a month. If Hopkins falls, there are others that will be falling too. This is pretty sad because three of my classmates are in this program.
Natalie

wow.
here is the most complete story I’ve found so far:
Hopkins Cited
Lisa

below is the statement Hopkins gave to employees about this situation. thought it might be of interest.
hey Natalie, just curious, who do you know that's in the IM program here? all the residents and interns pass through my service at some point so I probably know them.
Beth
Johns Hopkins fully supports the Accreditation Council for Graduate Medical Education's (ACGME) new rules for residents' work hours. On August 20, the ACGME's Residency Review Committee (RRC) in Internal Medicine informed us that certification of the Internal Medicine training program at The Johns Hopkins Hospital will be withdrawn July 1, 2004. The principal criticism of the program concerned non-compliance with the new restrictions on work hours. We are considering alternative courses of action proposed by the ACGME in order to maintain a Graduate Medical Education program in internal medicine and avoid disruption of our training program.
Over the past several years Johns Hopkins has been planning significant changes in resident work schedules and has increased the financial and manpower resources necessary to bring about these changes while continuing a high standard of patient care. We already have implemented measures to comply with the new work hour rules and look forward to demonstrating a collaborative relationship with the ACGME.
We have a strong commitment to our residents and fellows to avoid any disruption in their clinical training at Johns Hopkins and to ensure the continuation of the exceptional educational opportunities offered them here. The ACGME has encouraged us to take steps that will maintain the accreditation of our residency program in Internal Medicine, acknowledged as being among the finest in the nation. Ninety-nine percent of its residents pass their board examinations, one of the best rates of success in the country. We feel that we will emerge from this experience with the ACGME with an even stronger program that is in full compliance with new work hour rules.
The Johns Hopkins Hospital has 62 other residency programs that are not part of the current action.

While I sympathize with the residents in the program for the anxiety this must certainly be causing, I still personally applaud the ACGME’s action.
Are they “making an example” out of Hopkins? Quite possibly, and if so, GOOD. Maybe other programs will learn from it. From the responses from Hopkins (at least as reported in the article, and newspapers are an admittedly unreliable source), it appears that the program felt that based on their reputation they didn’t have to comply. This requirement was not a surprise to anyone. The programs have had plenty of time to figure it out IF (and this is a big if) they are committed to it. The programs need to develop the mindset that this is in the best interest of the patients and students, and get behind and support the rules, rather than fighting them tooth and nail.
I feel strongly about this issue not just as a medical student who will be living and working under these rules some day, but as a person who has had a family member hospitalized at a teaching hospital. Looking at the absolutely exhausted, blurry eyed doctors, and knowing they are responsible for the care of a seriously injured loved one, will be operating on that loved one… I didn’ t want those exhausted zombies anywhere near my family member! I don’t buy the argument that sleep deprivation trains better physicians. I think the research into the physiology of sleep deprivation disproves that. I’d have to see some evidence to the contrary to believe otherwise.
I’m glad they are trying to put some teeth into the rules. The violations may be “minor”, in which case Hopkins should be able to fix them easily enough. I think it’s funny that they are claiming “minor” when they were walking such a thin line anyway. There is no requirement that residents work 80 hours a week-- they should aim for less, and have some leeway in case things come up.
Just my two cents.
Epidoc

Hopkins has absolutely no excuse. They KNEW the RRC was cracking down, but they have a high and mighty opinion of themselves so they felt that they didnt need to comply.
I hope the RRC revokes their accreditation for a whole year, regardless of how Hopkins tries to con the RRC in their claims of “minor violations”, “no big deal”, “all problems are fixed” etc.
Its a good thing that Hopkins was knocked off their pedestal. I hope the RRC stands firm and doesnt let Hopkins squirm its way back like nothing happened. They need to be punished and pay the piper.

QUOTE (MD/PhD slave @ Aug 29 2003, 02:54 PM)
Hopkins has absolutely no excuse. They KNEW the RRC was cracking down, but they have a high and mighty opinion of themselves so they felt that they didnt need to comply.
I hope the RRC revokes their accreditation for a whole year, regardless of how Hopkins tries to con the RRC in their claims of "minor violations", "no big deal", "all problems are fixed" etc.
Its a good thing that Hopkins was knocked off their pedestal. I hope the RRC stands firm and doesnt let Hopkins squirm its way back like nothing happened. They need to be punished and pay the piper.

Hi there,
I am not so punitive since I have three classmates who are in this program and risk graduating from a non-accredited program. This means that after three years of residency, they will not be able to sit for Internal Medicine Boards unless they find an accredited program that is willing to take them for an extra year. It's not their fault that their residency administration allowed violations to go on. They are just folks who have studied hard and gotten into an excellent residency program and done a good job. They deserve to finish regardless of changes done by the RRC.
It is nice to say that the "high and mighty" should fall but my HUCM "02" folks are far from "high and mighty" and are bearing the brunt of this ruling. This is a very sad situation for every resident in that program in every sense and I feel very badly for them.
Natalie sad.gif

It has nothing to do wtih the students, I was referring to the faculty and program directors. They are the problem, not the residents (although from the article apparently some of the residents just dont get it that RRC regulations are no joke and you cant just blow it off)
If there was a way to punish Hopkins without punishing the residents, then I'm all for it. However I dont think thats possible. Unfortunately for them, the residents are inseparable from the program at large.
Everybody in medicine knows that if the RRC didnt aggressively enforce the rules, then most hospitals would just pay lip service to them and be in violation. I'm glad the RRC is being aggressive and showing that these regulations are not trivial and programs not in compliance WILL get burned.

As I understand it, the students in there third year of residency will be alright, since it won't take effect for another year-- they will be considered to have graduated from an accreditated program. If I were first year residents, I'd be looking at options. The ones I really feel for are the second years. Still, looking at it from a public health sort of perspective, you do what's best for the most— and enforcing these regulations and cracking down on those who refuse to abide is in the best interest of many, many people, residents and patients alike, as compared to the 106 residents in that program. That doesn't mean I don't feel for them.
Epidoc

QUOTE (Epidoc @ Aug 29 2003, 07:27 PM)
As I understand it, the students in there third year of residency will be alright, since it won't take effect for another year-- they will be considered to have graduated from an accreditated program. If I were first year residents, I'd be looking at options. The ones I really feel for are the second years. Still, looking at it from a public health sort of perspective, you do what's best for the most--- and enforcing these regulations and cracking down on those who refuse to abide is in the best interest of many, many people, residents and patients alike, as compared to the 106 residents in that program. That doesn't mean I don't feel for them.
Epidoc

Hi there,
My classmates ARE second-year residents in Internal Medicine. They have very few options in terms of finding another program since few programs are willing to take residents who have spent two or three years in other programs. It is almost impossible to find a residency that has senior positions unfilled. The folks who come out this year have no problems. The folks who are PGY-2s are in pretty bad shape.
These folks were the top of my class and worked very hard to get into a very competitive Internal Medicine residency. These folks graduated second, third and fourth in my class. Say what you want about Hopkins but they are the top program and many folks aspire to do their medical training there.
The lesson in all of this is that sometimes things are out of your hands as a resident. My classmates do not deserve to be "made an example of" or their hard-fought careers ruined. These are not medical students, they are residents and do have tons of options out there. The first-year residents do not deserve to have to go back into the match to find another program. It is not as easy to just switch programs or "look at other options" when you have made a three year commitment.
Natalie

Natalie -
A lot of good people, smart people, top of their class people, are sitting up here in Chicago after the Arthur Andersen debacle and subsequent fall with their careers in pieces. Whether it’s medicine or accounting, once you become a paid professional, there are risks.
My friends did not deserve to “be made an example” either, even if they are accountants or consultants rather than residents.
Susan - Chicago/Minneapolis

Natalie,
No one is saying this will be easy, or indeed anything other than excruciatingly painful for the residents involved.
But what it the option? To allow programs to simply violate the rules? To make the penalty a mere slap on the wrist- in essence to make the rules meaningless? I'm sorry, as much as I feel for the residents, I feel MORE for the patients whose protection should be paramount. If someone can't drive when sleep deprived, if pilots must have a mandatory amount of rest, I think someone treating hospitalized patients should have adequate rest.
I guess another lesson to be learned here is that when investigating a residency program, I guess there will be even more things to check into-- I'm sure no one suspected Hopkins would lose accredidation, I'm not saying that these residents could have suspected that— but for those of us still moving up the ladder, we'll need to look at that factor. There are new rules to the game.
Epidoc

I have been working on an insightful reply to this…but, in the interest of providing quality info, I am gonna work more on it before posting. Right now, it is a rather schizophrenic read. But suffice it to say that there is nore to these new work rules than benefiting patient & resident safety - which I whole-heartedly support. The complications come in the “how” of implementation, the extent subculture of medicine & designating the individual resident as responsible for both self-policing & reporting of crimes to an, in many cases, unsupportive attending staff/senior resident corps. Furthermore, allegedly, the policies state that if one program at a training facility goes onto probation for violating the work hours restrictions, then ALL of the programs there go onto probation. One of my chiefs “confirmed” that this policy is, indeed, not a rumor but a reality.
So, you have now shouldered the individuals with the obligations to: 1) self-police, 2) report violations to persons frequently unsupportive of the new regulations & 3) report things that potentially will land your own program (& possibly the entire training facility) on probation or have thier accreditation jerked. Does anyone besides me see the immense conflict of interest here?
The devil is not in the intention, it is in the implementation of the new policies…more, much more to follow.

some thoughts from today’s Washington Post on this topic…
It’s Hard To Do No Harm When You’ve Had No Sleep
I agree with Dave, the devil is in the details on this thing as I hear residents trying to hash out how they can do their job, learn what they need to, and still comply. It is NOT easy. Natalie’s program did what EVERY program should have done last year, try out schedule changes and see how to make it work BEFORE July 1. I know this was being done on some of my rotations, too, but not others… and those folks are really being caught in a dilemma now.

QUOTE (Epidoc @ Aug 30 2003, 11:12 AM)

I guess another lesson to be learned here is that when investigating a residency program, I guess there will be even more things to check into-- I'm sure no one suspected Hopkins would lose accredidation, I'm not saying that these residents could have suspected that--- but for those of us still moving up the ladder, we'll need to look at that factor. There are new rules to the game.
Epidoc

Hi there,
You can look all you want but you can be several years into your residency when the rug is pulled out and your program loses accreditation. The residents are responsible for policing the hours in the program. So here you are, a PGY 3 or 4 who is over the 80 hours. Are you going to jeopardize the work you have done previously and report to the RRC or are you going to keep your mouth shut and not let all of your work go down the drain? If you can't sit for specialty boards (and you won't be able to do this graduating from a program that is not accredited), what is the use of doing a residency in the first place? You can be happily in a program that you chose based on what you were told on interview day(you only see what they want you to see during residency interviews) and as you are happily toiling away, you find that the program has been skirting the regulations. What you going to do after you have bought a house and your family is settled in waiting for you to finish residency and have one year to go?
All of the investigation in the world will not ensure that once you start a program, you will be able to finish because of rules that change and are changing almost on a monthly basis. All of this stuff looked great on paper but implementing these changes have far reaching consequences that most programs have not worked out. I was on the interview trail two years ago and many programs said that they were aware of the new regs that were in the pipeline and were working on them. One of those programs was Johns Hopkins.
Natalie
QUOTE (njbmd @ Sep 2 2003, 10:06 AM)
Hi there,
You can look all you want but you can be several years into your residency when the rug is pulled out and your program loses accreditation. The residents are responsible for policing the hours in the program. So here you are, a PGY 3 or 4 who is over the 80 hours. Are you going to jeopardize the work you have done previously and report to the RRC or are you going to keep your mouth shut and not let all of your work go down the drain? If you can't sit for specialty boards (and you won't be able to do this graduating from a program that is not accredited), what is the use of doing a residency in the first place? You can be happily in a program that you chose based on what you were told on interview day(you only see what they want you to see during residency interviews) and as you are happily toiling away, you find that the program has been skirting the regulations. What you going to do after you have bought a house and your family is settled in waiting for you to finish residency and have one year to go?
All of the investigation in the world will not ensure that once you start a program, you will be able to finish because of rules that change and are changing almost on a monthly basis. All of this stuff looked great on paper but implementing these changes have far reaching consequences that most programs have not worked out. I was on the interview trail two years ago and many programs said that they were aware of the new regs that were in the pipeline and were working on them. One of those programs was Johns Hopkins.
Natalie

QUOTE
Hi there,
You can look all you want but you can be several years into your residency when the rug is pulled out and your program loses accreditation. The residents are responsible for policing the hours in the program.

It is the program director who is in charge, he/she is the person who has the responsibility to make sure the residents are not averaging more than 80 hours/week.
QUOTE
You can be happily in a program that you chose based on what you were told on interview day(you only see what they want you to see during residency interviews) and as you are happily toiling away, you find that the program has been skirting the regulations. What you going to do after you have bought a house and your family is settled in waiting for you to finish residency and have one year to go?

You go to the PD and say this: "hey you are screwing all of us. If the RRC catches what you are doing, all of us are in trouble. Grow up and start following the regulations."
the PD is the one breaking the rules--he/she is in charge, not the resident. PDs who blatantly ignore regulations need to be outed and fired on the spot. If we cheated on tests, how much mercy do you think we would get from the med school?
QUOTE
All of the investigation in the world will not ensure that once you start a program, you will be able to finish because of rules that change and are changing almost on a monthly basis. All of this stuff looked great on paper but implementing these changes have far reaching consequences that most programs have not worked out. .

Frankly, thats a copout argument. These regulations are NOT rocket science people, and they HAVE NOT changed every month either. The regulations clearly state that residents must not average more than 80 hours/week over a 4 week period. I dont buy the argument that the regs are too complex to understand. In fact they are quite simple. If somebody cant understand the regs, how are they going to understand a complicated diff dx?
QUOTE
I was on the interview trail two years ago and many programs said that they were aware of the new regs that were in the pipeline and were working on them. One of those programs was Johns Hopkins

Did you ever consider the possibility that they were lying/misleading you in an attempt to prop up their program? Clearly Hopkins either was too ignorant of what was going on (which constitutes incompetence) or they willfully ignored/skirted the rules (negligence). Either way, it speaks volumes about the program directors at Hopkins. They are 100% in the wrong here.



MD/PhD,
Oh but you are incorrect my friend…it may make the most sense, from a normal perspective, that the PDs & Chairs are ultimately the responsible parties. And, the language of the policies may even state that - to be honest, I have not taken the time to thoroughly read the policies. However, in the real world implementation of these new rules, how Nat & I are describing it is how it is. Individual residents are expected both self-police & report violations within their own & other programs. To report a problem, legit or not, essentially places your own program & potentially your entire training institute in accreditation jeopardy.
You can argue until you are blue in the face that the Admin-types are the ones who are responsible, and in an overall gestalt, they are. BUT, even if they are disciplined by program, ACGME or otherwise - they remain attending, board certified attending physicans with tons of employment options. We, the residents, are the ones left toiling in a program that may not be accredited at our graduation and we have ZERO options or avenues of recourse.
Remember, this is not the business professional world. This is the world of professional medicine that has a long history of a very paternalistic, almost predatory system of training its own. Med school & residency is very similar, esp in certain specialties/subspecialties, to a protracted fraternity pledging. Not all programs are this way for certain, but many, if not the majority, of the attendings were trained in such an environment & it cannot help but color how they teach.
The progressive thinking ones have used their experiences to instill a sense of advocacy for current residents. These are the ones spearheading & supporting these reforms. But, there is a significant “old guard” who tacitly & overtly do not support this…they are from the “old school” and have the strengths of history & traditional on their side - neither being forces to be ignored. The reformers are fighting an uphill battle that can & must be won; but it will take time, savvy and the arts of balance & politic to to do so. As anyone knnows, a set of rules can be massaged & perverted to the point where they undermine themselves. The old guard does not want things to change…this is a way of facilitating a lack of change.
Furthermore, I hope I am pointing out the obvious to you - as in your were trying to emphasize a point & not suggest actual tactics - even with the most receptive PDs & Chairs, you do not march in and make demands or deliver ultimata. In common English, that is called “shitting where you eat”. Without saying, that ain’t a smart way to proceed. As in any profession, you will get much further by approaching your superiors in a mature & professional manner with facts ready to defend your assertions.

I am a med student at Hopkins, so if anybody on this board has reason to support the IM dept, its me.
I still support the ACGME. I cant believe some of you are suggesting that the ACGME just ignore their own rules and look the other way.
I ask again, if I’m caught cheating on a med school test exactly how forgiving are they going to be? I’m telling you right now they’d kick me out of school no questions asked.
Thats exactly what these programs are doing, they are cheating because they think they are above the rules and that the rules dont apply to them. Just as the test cheater makes up excuses like “everyone else is doing it, theres too much to cover, I’m not hurting anybody” etc so too are these programs making BS excuses and whining like 2 year old children.
I expect more out of the so-called “leaders” of medicine than whining and complaining about the rules.
There are really 2 streams of thought going on in this thread–1) should residents report violations; 2) should the ACGME crackdown; 3) should these rules exist at all.
1, 2, and 3 are separate from each other. In this case, somebody has already reported the violations. Thats another thing that needs to be cleared up–the ACGME doesnt just take anonymous phone calls and then shut down the program immediatley. They do their own thorough investigation regarding the claims. If they find clear and compelling evidence that the program is in violation, ONLY then do they act.
Some of you guys are insinuating that the ACGME just said “Hey lets screw with Hopkins that sounds like fun” with no evidence of wrongdoing. Does anybody really believe that? I think thats pretty naive. In my mind, the following things are clear:
1) Hopkins KNEW about these regs
2) Hopkins was either incompetent or negligent in following the regs
3) Hopkins KNEW the ACGME was serious about the regs (see Yale surgery)
Again, if somebody can give me a way to punish Hopkins IM without hurting the residents, I’m listening. So far I’ve heard nothing but concerns about the plight of the residents. I do sympathize, but when you weigh enforcing the regulations vs the residents situation, I have to fall on the side of the ACGME. They cant just ignore the regs and look the other way. There’s too much at stake.
Maybe the punishment handed down by the ACGME is too severe, I believe thats a separate conversation though from the heart of the matter that Hopkins screwed up and needs to face the consequences.
We took a year-long ethics course which emphasized responsibility, leadership, honesty, and integrity. Any program director who doesnt ensure that his/her residents are in compliance has a serious problem with integrity and responsibility and needs to be punished. If it can be shown that the PD KNOWINGLY violated the regs, then they should be fired on the spot. Of course the upper leadership at Hopkins wont do that because they dont believe in the same values of responsibility and integrity that they teach to the med students here.


Quote: (Sorry I’m not sure how to uset the quote thing)
"All of the investigation in the world will not ensure that once you start a program, you will be able to finish because of rules that change and are changing almost on a monthly basis. All of this stuff looked great on paper but implementing these changes have far reaching consequences that most programs have not worked out. I was on the interview trail two years ago and many programs said that they were aware of the new regs that were in the pipeline and were working on them. One of those programs was Johns Hopkins."
I think there was a post some time ago on what to look for in a residency program, with several specific suggestions on what to ask, and suggestions on how to find the truth, and I’ve seen lots of advice on how to really check into a program, and on how to dig a little. Will it solve the problem completely? Of course not. A program can always pull the wool over your eyes… but I think there are signs on whether or not a program is planning to do something or not. Also, I think in the years to come it will be a little easier to look into, as programs will develop track records. Hopkins HAD been cited for violating 80 hour weeks in previous accredidations (which has long been a rule in IM programs), if I read the article correctly. Those things can be looked into. Lots of work- hell, yes, but worth it.
Natalie, you commented that John Hopkins said they were working on coming up with ways to abide by the new regs when you were interviewing— I assume you interviewed with the surgery program. Has the surgery program been caught violating the rules, too, or were they true to their word?
I don’t mean to be argumentative here, although I’m aware that is how it may sound, but I think a point needs to be made that we (med students and residents) are NOT totally helpless victims here. There ARE things out of our control, but there are things we can do to help ourselves, too.
1. Residents, AS A GROUP, must insist that their programs abide by the regulations, before it comes to the point where someone feels it must be reported to ACGME.
2. We must continue to push for laws that support the limited work hours, with harsh penalties to THE HOSPITALS that overwork residents.
3. Insist on whistleblower protection, and provisions for assisting residents who are in programs that lose accredidation in finding residencies.
This is a transistion time in medical training–a sea change. It will take time, and it won’t be easy or smooth. Lamenting the enforcement of the regulations doesn’t really help though. Finding ways to “motivate” the programs to change might.

Okay, enough from me on this issue, I guess. Now I have to go back to reading papers on “patient autonomy” for my ethics class in the morning.
It’s nice to have a board where things can be discussed so openly and civilily, even when opinions differ.
Epidoc

QUOTE (Epidoc @ Sep 2 2003, 08:10 PM)

Natalie, you commented that John Hopkins said they were working on coming up with ways to abide by the new regs when you were interviewing--- I assume you interviewed with the surgery program. Has the surgery program been caught violating the rules, too, or were they true to their word?

Hi there,
I was invited to interview by the Hopkins Anesthesia program. I did not apply to the Hopkins Surgery program.
Natalie

I may perhaps be showing the depth of my ignorance regarding the residency process, but here goes…
My feeling is that the changes in regs limiting resident work hours to 80 hrs/week are an important change, and need to be implemented for the good of all concerned (providers and patients as well). I can speak from personal experience on this - sleep deprivation is an ugly thing. Compelling another to undergo the effects of sleep deprivation and continue to effectively work / care / learn / heal seems to me somewhat perverse, at best. That the the patients' care should be compromised by residents who are in a compromised state is even worse.
It seems to me that, realistically, there will be some programs that will not take action unless they perceive a threat of real consequences for breaking the rules.
But who is to pay the price for non-compliance? Natalie's friends in PGY-2 in the Hopkins program are in a real bind, as are the first-year residents, to a lesser extent. Do they deserve to be put into the situation that they find themselves in now? My gut says no.
Rather than de-certify a program mid-stream and potentially strand the current residents without any palatable options, why not simply shut the valve at the other end of the pipe? By this I mean - decertify the program for a year, two years (or however long the quantity and severity of the infractions warrant) from next year forward?
This would (hopefully) be a major red flag for anyone considering matching to the program, and would avoid creating the situation that the current Hopkins IM residents find themselves in.
Perhaps what I've suggested is totally naive; feel free to poke any holes that need to be poked…
-Ted